Pelvic Pain

Pelvic pain is one of the most common presenting complaints in female patients visiting a gynaecologist. Because of the complex anatomy of the female pelvis, pain originating from the pelvis can arise from problems in different body systems and it is important to find out the root cause of the pain before commencing treatment. This is to ensure that the patient receives the best and most appropriate treatment for her condition.

The pelvis houses many important organs, including the bladder, intestines, rectum and, most relevant to a gynaecology patient, the female reproductive organs. The pelvic organs reside within the bony pelvis which functions as a form of mechanical protection for these organs. Pathologies involving any one of these structures, including the bony pelvis, can result in pelvic pain.

Generally, pains which are cyclical in nature and typically associated with the menstrual cycle are highly suggestive of (pathology) problems with the female genital system. The female reproductive system can be divided into internal and external genitalia. The internal genitalia refer to the reproductive organs found within the body cavity, including the ovaries, fallopian tubes, uterus and vagina. The external genitalia refer to the vulva, including the vaginal orifice and urethral opening.

Female genital organs are the most common source of pain in women of reproductive age. Due to the complexity of the female genitalia, many different types of problems occurring at different parts of the reproductive system can lead to pelvic pain. An ovarian cyst larger than 5cm in diameter can cause acute or sharp pain when it twists on its own stalk or bleeds into itself. Pain due to this is usually spasmodic at the beginning, gradually escalating in intensity until it becomes a constant, severe, one-sided pain in the pelvis. Cysts may also rupture, leading to an acute abdomen which requires emergency surgery.

Other causes of pelvic pain arising from the internal genitalia include endometriosis, uterine fibroids, and pelvic inflammatory disease.

Endometriosis is a condition characterised by the growth of endometrial tissue outside the uterine cavity, usually in the ovaries. Pains due to endometriosis tend to peak at menstruation and coital pain and changes in bowel habits are also possible accompanying symptoms. It is important for women affected by endometriosis to get diagnosed and treated early because it is a common cause of infertility.

Uterine fibroids can cause pressure and pains depending on the site and size of the fibroids. The ones that cause the most symptoms are the submucosal variety. Although small, they protrude into the uterine cavity, causing painful and heavy menses. The larger intramural ones tend to cause more pressure symptoms and heavier menses as they enlarge the entire uterine cavity.

Pelvic inflammatory disease (PID) is a collective term describing inflammation of the adnexae (fallopian tubes and ovaries) and uterus. This can be caused by the insidious progression of an often ignored bacterial vaginosis, as the disease-causing bacteria travel upwards into the upper reproductive tract causing infection and inflammation of the uterus and adnexae. Chronic inflammatory conditions such as PID typically involve scar formation and adhesion to nearby tissues. In PID, inflammed organs tend to be adherent to one another and this relative immobility tends to lead to severe pain, infertility and ectopic pregnancy. Typically, patients with PID present with cervical or vulvovaginal tenderness and lower abdominal pains with abnormal vaginal discharge. There may also be fever and associated gastrointestinal symptoms such as nausea, abdominal distension and diarrhoea, depending on the extent of the infection.

Besides gynaecological problems, pathologies involving other pelvic organs should also be considered in patients with pelvic pain. These include urinary tract infection, inflammatory bowel disease, irritable bowel syndrome and appendicitis. Conditions arising from the urinary system are usually associated with pain while passing urine and increased frequency of urination. Intestinal conditions usually come with increased flatulence and changes in bowel habits and consistency of stools.

Due to the wide variety of possible causes behind pelvic pain, patients are advised to visit a family physician as soon as symptoms arise to find out the root of the problem. A comprehensive medical history obtained by an experienced physician, with the aid of certain examinations, can often pinpoint the causative reason. Treatment of gynaecological pelvic pains depends on the cause, ranging from simple oral administration of antibiotics and painkillers to surgery. A gynaecologist will be able to offer appropriate advice to the patient regarding suitable treatment methods based on clinical history and specialist investigations.

Dr Ann Tan is the first Singaporean to hold the Diploma of Fetal Medicine from the Fetal Medicine Foundation. She presently serves on the Women’s Health Advisory Committee at the Health Promotion Board. Dr Ann Tan was a Public Service Commission Scholar, and has won several prestigious awards in her field of specialization.

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